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oRIGINAL CONTRIBUTION

pediatric

weight estimation,

A Rapid Method for Estimating Weight and Resuscitation Drug Dosages From Length In the Pediatric Age Group

Drug dosages used during pediatric emergencies and resuscitation are often based on estimated body weight. The Broselow Tape, a tape measure that estimates weight and drug dosages for pediatric patients from their length, has been developed to facilitate proper dosing during emergencies. In our study, 937 children of known weight were measured with this tape. Weight estimates generated by the tape were found to be within 15% error for 79% of the children. The tape was found to be extremely accurate for children from 3.5 to 10 kg, and from 10 to 25 kg. Regression lines of estimated com- pared with actual weight for these children have dopes of 0.98 and 0.96,

respectively, not significantly different from the ideal slope of 1.00 (P = 28

and .13). Accuracy was significantly decreased for measured children

who

weighed more than 25 kg. In a separate group of children (n = 53), the tape was shown to be more accurate than weight estimates made by residents and pediatric nurses (P < .0001). Use of the Broselow Tape is a simple, accu- rate method of estimating pediatric weights and drug doses and eliminates

the need for memorization and calculation. [Lubitz DS, Seidel JS, Chameid- es L, Luten RC, Zaritsky AL, Campbell FW: A rapid method for estimating weight and resuscitation drug dosages from length in the pediatric age group. Ann Emerg Med June I988;17:576-58i.]

INTRODUCTION

Drug dosages and fluid therapy used for pediatric resuscitation vary and are

based on the patient's body weight. In a crisis situation, health care person- nel may be unable to weigh patients, and the weight is estimated. The esti- mated weight then is used to calculate drug dosages by referring to charts, cards, or memory for the appropriate dose per kilogram of body weight. Most methods currently used to estimate body weight in children are based on age.l,z Recently, several methods have been developed to estimate

body weight based on height,3, 4 and James Broselow

plified method of rapidly estimating weight based on heights In 1979, the National Center for Health Statistics (NCHS) published a new set of percentile curves for assessing the physical growth of children in the United States using data collected by the NCHS between 1963 and 1975.6 This was done by examining a group of children chosen by a nationwide probability sample designed by the NCHS and the United States Bureau of Census. The examination and measurement processes were standardized. Careful application of statistical sampling weights to the sample of more than 20,000 children resulted in an effective representation of all children in the United States to the age of 18 years. These growth charts are well accept- ed and widely used.

Using the NCHS data, Broselow determined the 50th percentile weight for many lengths and heights. This was translated to a measuring tape with spaces labeled with weights in kilograms instead of units of length (Figures 1 and 2). The appropriate doses for many resuscitation drugs, calculated from the estimated weight and the American Heart Association (AHA) recom- mendations,7 are printed in each space (Figure 3). Our multicenter study was undertaken to evaluate the accuracy of weights estimated by this tape.

has developed a sim-

17:6June 1988

Annals of Emergency Medicine

Deborah S Lubitz, MD* James S Seidel, MD, PhD* Torrance, California Leon Chameides, MDt Hartford, Connecticut Robert C Luten, MD:~ Jacksonville, Florida Arno L Zaritsky, MD§ Chapel Hill, North Carolina Frederick W Campbell, MDII Philadelphia, Pennsylvania

From the Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California;* the Department of Pediatrics, Hartford Hospital, University of Connec- ticut School of Medicine, Hartford, Con- necticut;l- Departments of Emergency Medicine and Pediatrics, University Hospital of Jacksonville, University of Florida College of Medicine, Jacksonville;:~ Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill;§ and Department of Anesthesia, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia.II

Received for publication December 21, 1987. Accepted for publication March 1, 1988.

Presented at the Ambulatory Pediatric Association Annual Meeting in Washington, DC, May 1988.

Address for reprints: James S Seidel, MD, PhD, Box 21, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, California 90509.

576/43

PEDIATRIC TAPE MEASURE Lubitz et al

FIGURE 1. The Broselow Tape. Spaces are labeled with the estimated weight corresponding to the measured length.

FIGURE 2. Measuring a child from head to heel. This child weighs 15.9 kg, and her length falls into the 15-kg space on the tape (the dark space aligned with her heel).

MATERIALS

AND

METHODS

Children from one week to 12 years old were enrolled in our study at five institutions, from August to October 1986. Data were collected on pediatric patients seen in the emergency depart- ment and outpatient clinics of Harbor- UCLA Medical Center in Los An- geles; the ED of University Hospital in Jacksonville, Florida; the pediatric cardiology clinics at Hartford Hospital

in Connecticut; the pediatric inten- sive care unit and clinic, University of North Carolina at Chapel Hill; and in the operating suite at Children's Hos- pital of Philadelphia. Age (to the near- est month}, sex, ethnic background, and diagnosis were recorded for each child. Patients were weighed to the near- est 0.1 kg on either a table or upright scale, depending on ability to stand. Length (or height} was measured to the nearest 0.1 cm. A prototype of the Broselow Tape was used to measure the child's length in the recumbent position, from crown to heel. The study tapes were marked with 33 spaces, numbered from 1 to 33. Each space corresponded to an estimated weight in whole kilograms. The space on the tape into which the child's length fell was noted. The evaluators were blinded to the relationship be-

tween the numbered

tape and the estimated weight corre- sponding to the space. After all data were collected, the es- timated weight (tape weight), in whole kilograms, for each child was derived from the relationship between weight and length developed by Broselow. The estimated tape weight versus the actual weight were plotted, straight lines were fitted through the data using linear regression analysis, and the slopes of the resulting lines were analyzed. Comparisons of observed slopes with expected slopes were made with a t test. Error and percent error of the tape weight from the actu- al weight were calculated. A comparison was made between

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spaces on the

A comparison was made between 44/577 spaces on the TABLE 1. Age and weight distribution of

TABLE 1. Age and weight distribution of study population

Age

No. (%)

Weight (kg)

No. (%)

<lyr

430

(44)

<

3.5

51

(5)

1-4 yr

309

(31)

3.5-10

395 (40)

4-8 yr

185

(19)

10-25

449 (45)

8-12 yr

64 (6)

 

25-40

93

(9)

 

>

4"0"

10

(1)

Total*

988

1,002

*Age not recorded for 14 patients.

the Broselow Tape and the most com- monly used method, estimation of weight based on age. An additional group of 53 children between 1 month and 11 years old who were seen in the pediatric ED at Harbor-UCLA Medical Center were weighed and measured as described above by a single observer. The child's weight then was estimated

Annals of Emergency Medicine

by three separate individuals selected from a group of pediatric residents, emergency medicine residents, family medicine residents, and pediatric emergency nurses. The "estimators" were told the child's age and observed the child unclothed, sitting, and/or supine. Absolute values for the error and percent error were calculated; cot-

17:6 June 1988

FIGURE 3. Calculated drug dosages as they appear on the tape.

FIGURE 4. Regression analysis of ac- tual weight versus tape weight for subjects from 3.5 to 40 kg (n = 937).

nificant differences in the accuracy of the tape for boys versus girls or among ethnic groups. Accuracy for patients | with chronic cardiac and neurologic disorders did not significantly differ from that for healthy and acutely ill children. As a result, the entire data set was pooled for analysis. The weight of the population ranged from 2.05 to 51.10 kg, and length ranged from 43.00 to 145.10 cm. The increments on the tape begin at 53 cm, with the first space, number 1, corresponding to 4 kg. The last space,

number 33, corresponds to an esti- mated weight of 36 kg. A number of children initially enrolled in this study exceeded the range of the tape in its prototype form, so the data for the children less than 3.5 kg and those greater than 40 kg were discarded. Tape weight versus actual weight was plotted for the remaining set of sub- jects (n = 937). When linear regres- sion analysis (y = a + bx) was per-

p~

3 4~ 3~ 3~ °6 J 3~ 32 T 3e A 2G p 26" E
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24"
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IIIIIIIIllll~ll~IIll
2
4
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8
10
12
14
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20 22 24
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30 32 34
36 38
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ACTUAL WEIGHT
estimated weight ?or
each subject
~
re~ression line with
slope 0.89~
r
(n = 937)
=
.97
4

RESULTS The children in this study (N = 1,002) ranged in age from 2 weeks to 10 years, 11 months old, with 57% boys. The age and weight distributions are given (Table 1). There were no sig-

Annals of Emergency Medicine

formed, the result (Figure 4) was a line with the equation: tape weight = 1.01

+

0.89 (actual weight), r

=

0.97.

The data were grouped into weight ranges for analysis. For subjects in the 3.5 to 10 kg range (n = 395), the slope of the regression line is 0.98 with r = 0.89. For children from 10 to 25 kg (n = 449), the slope of the regression line is 0.96 with r = 0.93. For those weigh- ing more than 25 kg (n = 93), the slope falls off to 0.50 (r = 0.46). When these slopes are compared with the "ideal" slope of 1.0 by a two-tailed t test, the results are P = .28, P = .13, and P < .00001, respectively. This in- dicates that the slopes for the subjects between 3.5 and 25 kg do not signifi- cantly vary from 1.0, but in the group weighing more than 25 kg, there is

significant deviation from the desired slope of 1.0.

The accuracy of the tape was fur- ther evaluated by looking at the error for each subject between the actual weight and the tape weight. The error (actual weight - tape weight) ranged from -5.7 kg to +15.7 kg, with a

mean of +0.47

(SD = 1.93). This indi-

cates that, on the average, the tape tends to underestimate the weight by approximately 0.5 kg. This is a statis-

578/45

responding errors were obtained for the tape. The percent errors of the es- timates were compared with those of the tape in a two-way contingency table, and the significance was evalu- ated using Fisher's exact test.

17:6June 1988

PEDIATRIC TAPE MEASURE Lubitz et al

TABLE 2. Percent error of tape-generated estimates

% Error*

Total (%)

3.5-10 kg (%)

10-25 kg (%)

>

25 kg

(%)

Up to

+

 

10%

559 (59.7)

221 (55.9)

292 (65.0)

46

(49.5)

+

10%

-

15%

183 (19.5)

71 (18:0)

96 (21.4)

20

(21.5)

_+ 15%

- 20%

97 (10.4)

46 (11.7)

39

(8.7)

12

(12.9)

_+ 20%-25%

55

(5.9)

26

(6.6)

16

(3.6)

9

(9.7)

>

_+ 25%

 

43

(4.5)

31

(7.8)

6

(1.3)

6

(6.4)

Total

 

937

395

449

93

*(actual weight -

tape weight)x 100

 

actual weight

FIGURE 5. Comparison of tape weights and estimated weights by res- idents and nurses for 53 children.

tically significant bias (P < .0001), but is usually not clinically important. The mean error is -0.05 kg (SD = 0.95) in the 3.5 to 10 kg group, 0.39 kg

(SD = 1.62) in the 10 to

and 3.03 kg (SD = 3.67) in the more than 25 kg group. The percent error was calculated for each subject, and the distribution is shown (Table 2). Almost 60% (59.7%) of all the tape estimates are within 10% of the tree weight, and 79.2% are within _+ 15%. The percent error will necessarily be slightly more in the very young children, because every "space" (full-kilogram increments) away from the actual weight is a larger percentage of the whole (eg, if the tape estimates a 3.5-kg child to be 4 kg, the percent error is 14%, but this is as close as the tape can possibly be). The slopes of the regression lines of actual versus tape-estimated weight for children less than 25 kg are not significantly different from the ideal slope of 1.00, but the accuracy signifi- cantly decreases for children weighing more than 25 kg. The decrease in ac- curacy above 25 kg may be exagger- ated by the regression analysis data because of the small data set and con- siderable scatter. When the percent er- ror is calculated for this group, 49.5% are within 10% of the true weight (59.7% for the entire data set). An- other 21.5% are within 15% (cumula- tive 71%, compared with 79.2% for the entire set). The tape underesti- mated the actual weight by more than 20% in approximately 16% of these larger children. All of these children were noted by the evaluators to be obese.

25 kg group,

46/579

40-

35

3Er

25

2~

15

10-

5-

/' /I

0

2

[]

4

~

6

',

8

l

',

10 12

',

l

14 16

l 18 20 22 24 26

',

',

',

',

~

28

',

1

',

30 32 34

'ACTUAL WEIGHT

tape weight

estimated weight~

=

line

?or

slope

each subject

b~ residents

1.00

(n = 53) and nurse~

with

',

I

36 38

I

40

The 53 children enrolled in the ad- ditional evaluation of the tape ranged between 1 month and 11 years old, with weights from 4 to 31 kg. The ab- solute value of the errors for the tape weights ranged from 0 to 2.9 kg, with a mean of 0.66 kg (SD = 0.64). The errors for the weight estimates by resi- dents and nurses ranged from 0.02 to 8.9 kg, with a mean of 1.85 kg (SD = 1.87) {Figure 5). The distribution of the percent error is shown (Table 3). The tape weights are more often within t5% of the actual weight than the weights estimated by residents and

Annals of Emergency Medicine

nursing staff.(94% vs 63%; P < .0001 by Fisher's exact test).

DISCUSSION

Dosages of drugs and fluids given during pediatric emergencies and re- suscitation are calculated on a per- kilogram basis. Several methods have been developed to rapidly estimate body weight. Today's most popular methods use age-specific weights, either memorized or obtained from a reference chart. 2 This requires recall and/or immediate access to a chart. There are other factors that may con-

17:6 June 1988

TABLE 3. Percent

error of the Broselow

and

nurse

estimates

Tape

Tape weights

versus resident

Estimates

% Error

 

No.

%

No.

%

up

to

_+ 5%

30

57

35

22

+

5% to

10%

15

28

39

25

+

10%to 15%

5

9

26

16

+

15% to 25%

2

4

33

21

>

_+ 25%

1

2

26

16

Total

 

53

159

tribute to the inaccuracy of age-specif- ic weights. If the age is unknown, both age and weight must be esti- mated; the interval between memo- rized values is often wide; and normal weights for a given age may vary wide- ly, especially for older children. Recently, relationships between length and weight have been explored as a source of weight estimation. Length is a readily obtainable mea- surement, even in the setting of CPR. Length is strongly related to many bi- ologic processes such as glomerular filtration rate and intestinal absorp- tion, and is a stronger determinant of body surface area than is weight. 4 Methods to generate ideal body mass

as a function of height in adults were found to be useful in the determina- tion of the doses of drugs that pri- marily distribute to the fat-free mass. 8 A complicated formula for estimat- ing ideal body mass from length in children was developed by Traub and

Kichen. 4 They defined the

centile weight for height from the NCHS data as "ideal" because it repre- sents a child with average amounts of lean and adipose tissue for a given height. Their equation loses accuracy in taller children (especially those more than 154 cm tall). It was hypoth- esized that this was secondary to the exclusion of body frame as a variable

in older children and the increasing percentage of body fat. It is likely that the ideal weight will more accurately reflect the actual weight in younger children and infants because of their increased amount of total body water and lower percentages of body fat.9 This same 50th percentile measure- ment was used by Broselow in the de-

velopment

study. Garland and coworkers in Mil-

50th per-

of the

tape

tested

in

our

17:6June 1988

waukee developed a method for es- timating body weight from height and body habitus. 3 With this method, slim, average, and heavy children are those whose weights are taken from the 5th, 50th, and 95th percentile for their height. After height is measured and habitus determined, the estimated weight is obtained from a chart. In their study of 258 children, regression analysis of the actual versus estimated weight yielded a line with a slope of 1.04 when the regression line was forced through the origin (ie, an equa- tion of the form y = bx). They also found that 61% of the estimates were within 10% error. A stepwise multiple regression was performed, and they determined that length was the most important variable in estimating weight, followed by body habitus, and then age. In our study, a regression line with a slope of 0.95 was obtained when the regression line was forced through the origin (n = 937), and 59.7% of the es- timates were within _+ 10%, with 79.2% within _+ 15%. The tape is as accurate as the method developed by Garland and associates and is easier to use because there is only one variable. There is no need for the memoriza- tion of drug dosages or the perfor- mance of calculations because the dosages recommended by the AHA are already calculated and presented on the tape. The addition of an inter- val corresponding to 3 kg would fur- ther increase the utility of this tape. The decrease in accuracy of the tape demonstrated in our study for chil- dren weighing more than 25 kg was most likely due to the variations in weight and body habitus of these older children. Our data do show the in- creased scatter in this group. This de- crease in accuracy of more than 25 kg

Annals of Emergency Medicine

is of concern, and perhaps modifica- tion to include body habitus as a vari- able at the higher weights should be considered. The tape also was shown to be sig- nificantly more accurate than those weight estimates made from age and observation by residents and pediatric nurses, indicating its superiority over the method most commonly used to- day.

CONCLUSION The method of weight estimation used by the Broselow Tape is highly accurate, matching or surpassing other methods already common or proposed for use. The tape provides a rapid, accurate method of estimating weight and the necessary drug dosages for critically ill and injured children. The need for memorization and cal- culation, which are major sources of human error in pediatric weight es- timation and drug dosage calculations, is eliminated. The Broselow Tape is easy to use and should prove useful to both prehospital and ED health care providers.

The authors thank Jenny Keshishian and Patricia Walker for their help in man- uscript preparation, and Peter Christen- son, PhD, Department of Biomathemat- ics, UCLA, for assistance with statistical analysis. They also thank Cathy Ficere, PNP; Kim Ogle, MD; Rometa Dorter, RN; Kathy Nelson, RN; Michael Sharp, MD; and the staffs of the pediatric ED and clinics of Harbor-UCLA Medical Cen- ter; the pediatric cardiology clinics of Hartford Hospital; and the pediatric clinic of the University Hospital of Jacksonville for their contributions to data collection for our study.

REFERENCES

1. Tmssell J, BloomDE: A model distribution of

height or weight at a given age. Human Biology

1979;51:523-536.

2. Task Force on Pediatric Emergency Medi-

cine: Workbook for Advanced Pediatric Life

Support (APLS). Chapel Hill, North Carolina, American Academy of Pediatrics, 1984, p 74.

al: A

3. Garland JS, Kishaba RG, Nelson DB, et

rapid and accurate method of estimating body weight. Am J Emerg Med 1986;4:390-393.

4. Traub 8L, Kichen L: Estimating ideal body

mass in children. Am J Hosp Pharm 1983;40:

107-110.

5. Broselow J, personal communication,

1986.

July,

6. Hamill PVV, Drizd TA, Johnson CL, et al:

Physical growth: National Center for Health Statistics Percentiles. Am J C]in Nutr 1979;32:

6O7-629.

7. Standards and guidelines for cardiopulmo-

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PEDIATRIC TAPE MEASURE Lubitz et al

nary resuscitation and emergency cardiac care.

JAMA 1986;255:2905-2984.

from total body density and its estimation from skinfold thickness, Br J Nutr 1974;32:77-97.

orders in pediatric

patients,

in Purschctt PB

(ed): Disorders of Fluid and Electrolyte Balance.

 

New York,

Churchill

Livingstone,

1985, p

8. Durnin JV, Wornersley J: Body fat assessed

9. Ellis D, Avner ED: Fluid and electrolyte dis-

217-229.

American Board of Emergency Medicine Notice

On June 30, 1988, the practice option will terminate for those physicians wishing to meet the credential requirements of the American Board of Emergency Medicine's certification examination. Practice, teaching, or CME accumulated after the above date may not be used to satisfy the practice requirements, Questions should be directed to ABEM, 200 Woodland Pass, Suite D, East Lansing, MI 48823; 517/332-4800.

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Annals of Emergency Medicine

17:6 June 1988